Daniel J France1, Emma Schremp2, Evan B Rhodes2, Jason Slagle2, Sarah Moroz2, Peter H Grubb3, Leon D Hatch4, Matthew Shotwell5, Amanda Lorinc2, Jamie Robinson6, Marlee Crankshaw7, Timothy Newman2, Matthew B Weinger2, Martin L Blakely8. 1. Department of Anesthesiology, Vanderbilt University Medical Center, Suite 732, 1211 21st Avenue South, Nashville, TN, USA; Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA. Electronic address: dan.france@vumc.org. 2. Department of Anesthesiology, Vanderbilt University Medical Center, Suite 732, 1211 21st Avenue South, Nashville, TN, USA; Center for Research and Innovation in Systems Safety, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA. 3. Department of Pediatrics, Division of Neonatology, University of Utah, Salt Lake City, UT, USA. 4. Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA. 5. Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA. 6. Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, TN, USA. 7. Neonatal Intensive Care Unit, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA. 8. Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, TN, USA.
Abstract
BACKGROUND: Non-routine events (NRE) are defined as any suboptimal occurrences in a process being measured in the opinion of the reporter and comes from the field of human factors engineering. These typically occur well up-stream of an adverse event and NRE measurement has not been applied to the complex context of neonatal surgery. We sought to apply this novel safety event measurement methodology to neonates in the NICU undergoing gastrostomy tube placement. METHODS: A prospective pilot study was conducted between November 2016 and August 2020 in the Level IV NICU and the pediatric operating rooms of an urban academic children's hospital to determine the incidence, severity, impact, and contributory factors of clinician-reported non-routine events (NREs, i.e., deviations from optimal care) and 30-day NSQIP occurrences in neonates receiving a G-tube. RESULTS: Clinicians reported at least one NRE in 32 of 36 (89%) G-tube cases, averaging 3.0 (Standard deviation: 2.5) NRE reports per case. NSQIP-P review identified 7 cases (19%) with NSQIP-P occurrences and each of these cases had multiple reported NREs. One case in which NREs were not reported was without NSQIP-P occurrences. The odds ratio of having a NSQIP-P occurrence with the presence of an NRE was 0.695 (95% CI 0.06-17.04). CONCLUSION: Despite being considered a "simple" operation, >80% of neonatal G-tube placement operations had at least one reported NRE by an operative team member. In this pilot study, NRE occurrence was not significantly associated with the subsequent reporting of an NSQIP-P occurrence. Understanding contributory factors of NREs that occur in neonatal surgery may promote surgical safety efforts and should be evaluated in larger and more diverse populations. LEVEL OF EVIDENCE: IV.
BACKGROUND: Non-routine events (NRE) are defined as any suboptimal occurrences in a process being measured in the opinion of the reporter and comes from the field of human factors engineering. These typically occur well up-stream of an adverse event and NRE measurement has not been applied to the complex context of neonatal surgery. We sought to apply this novel safety event measurement methodology to neonates in the NICU undergoing gastrostomy tube placement. METHODS: A prospective pilot study was conducted between November 2016 and August 2020 in the Level IV NICU and the pediatric operating rooms of an urban academic children's hospital to determine the incidence, severity, impact, and contributory factors of clinician-reported non-routine events (NREs, i.e., deviations from optimal care) and 30-day NSQIP occurrences in neonates receiving a G-tube. RESULTS: Clinicians reported at least one NRE in 32 of 36 (89%) G-tube cases, averaging 3.0 (Standard deviation: 2.5) NRE reports per case. NSQIP-P review identified 7 cases (19%) with NSQIP-P occurrences and each of these cases had multiple reported NREs. One case in which NREs were not reported was without NSQIP-P occurrences. The odds ratio of having a NSQIP-P occurrence with the presence of an NRE was 0.695 (95% CI 0.06-17.04). CONCLUSION: Despite being considered a "simple" operation, >80% of neonatal G-tube placement operations had at least one reported NRE by an operative team member. In this pilot study, NRE occurrence was not significantly associated with the subsequent reporting of an NSQIP-P occurrence. Understanding contributory factors of NREs that occur in neonatal surgery may promote surgical safety efforts and should be evaluated in larger and more diverse populations. LEVEL OF EVIDENCE: IV.
Authors: Noa Segall; Alberto S Bonifacio; Rebecca A Schroeder; Atilio Barbeito; Dawn Rogers; Deirdre K Thornlow; James Emery; Sally Kellum; Melanie C Wright; Jonathan B Mark Journal: Anesth Analg Date: 2012-04-27 Impact factor: 5.108
Authors: Mehul V Raval; Peter W Dillon; Jennifer L Bruny; Clifford Y Ko; Bruce L Hall; R Lawrence Moss; Keith T Oldham; Karen E Richards; Charles D Vinocur; Moritz M Ziegler Journal: J Am Coll Surg Date: 2010-10-29 Impact factor: 6.113
Authors: Jan Maarten Schraagen; Ton Schouten; Meike Smit; Felix Haas; Dolf van der Beek; Josine van de Ven; Paul Barach Journal: BMJ Qual Saf Date: 2011-04-13 Impact factor: 7.035
Authors: Nathaniel H Greene; Rachel G Greenberg; Sean M O'Brien; Alex R Kemper; Marie Lynn Miranda; Reese H Clark; P Brian Smith Journal: Am J Perinatol Date: 2018-12-21 Impact factor: 1.862
Authors: Emma C Hamilton; Dean H Pham; Andrew N Minzenmayer; Mary T Austin; Kevin P Lally; KuoJen Tsao; Akemi L Kawaguchi Journal: J Surg Res Date: 2017-10-20 Impact factor: 2.192
Authors: Robert Chris Adams-McGavin; James J Jung; Anne S H M van Dalen; Teodor P Grantcharov; Marlies P Schijven Journal: Ann Surg Date: 2021-07-01 Impact factor: 12.969
Authors: Ayse P Gurses; George Kim; Elizabeth A Martinez; Jill Marsteller; Laura Bauer; Lisa H Lubomski; Peter J Pronovost; David Thompson Journal: BMJ Qual Saf Date: 2012-05-05 Impact factor: 7.035